Breech Presentation - An Overview

What Is A Breech Presentation?

Normally, the head of the baby will move closer to the birth canal a few weeks before birth. A breech presentation occurs when the fetus is lying longitudinally, and its buttocks or feet will be positioned to be delivered first. It happens in approximately 1 out of 25 full-term births. The probability of breech presentation decreases with the increase in gestational age (a measure of the age of a pregnancy taken from the beginning of a woman's last menstrual period to the date).

Why Does Breech Presentation Happen?

It happens due to the following reasons-

1. In multiple pregnancies.

2. When there is a history of prematurity.

3. When there is too much or too little amniotic fluid in the uterus.

4. When the shape of the uterus is abnormal due to any growths like fibroids, etc. Generally, the shape of the uterus is like an upside-down pear. If the shape is different, the space for the fully grown baby may be less to move into the position.

5. With women having placenta previa where the placenta covers all or part of the cervix.

6. Fetal abnormalities.

7. The previous history of breech presentation at term increases the risk of the same in subsequent pregnancies.

What Are the Types of Breech Presentation?

Approximately 20 % of babies are at a breech position at 28 weeks of gestational age. This spontaneously changes to a cephalic presentation in most babies where the head is positioned down to enter the vagina first. Only 3 % are breech at term. There are three main types of breech presentation depending upon the position of the legs.

It includes-

Complete breach (flexed)- (5 % to 10 %) both the legs are bent at the hips and knees.

Frank (extended) breech- (50 % to 70 %) both the legs of the babyface straight up and their feet near their head while the buttocks are aimed at the birth canal.

Footling breech- (10 % to 30 %)- one or both the feet are pointing downwards and will deliver before the rest of the body.

What Are the Clinical Features of Breech Presentation?

The diagnosis of breech presentation is not significant until 32 weeks to 35 weeks, as the fetus is likely to revert to a cephalic presentation before delivery. In 20 % of cases, breech presentation is not diagnosed until labor. This presentation is usually identified on clinical examination and cervical examination. On palpation of the mother's abdomen, the round fetal head can be felt in the upper part of the uterus, and irregular mass, which usually represents the fetal buttocks and legs, is felt in the pelvis. It can also be suspected if the fetal heartbeat is auscultated higher on the maternal abdomen. Signs of fetal distress, such as meconium-stained liquor, can also be there. On vaginal examination, the foot can be felt through the cervical opening.

What Are the Investigations Used?

If a breech presentation is suspected, it should be confirmed by an ultrasound scan. This can identify the type of breach and reveal any fetal or uterine abnormalities that may risk breech presentation during delivery. On ultrasound, the fetal lying position, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review should also be documented.

What Are the Risks and Complications Involved in Breech Presentation?

The importance of breech position is only during delivery. The complications of delivering a baby at breech position vaginally include-

• Injuring the baby's legs or arms, such as dislocated or broken bones.

• Umbilical cord problems- the umbilical cord can be flattened or twisted during delivery, and it can cause nerve or brain damage due to lack of oxygen.

• The baby's head may get entrapped.

• There can be premature rupture of membranes.

• Birth asphyxia- a condition where the baby does not receive enough oxygen before, during, or directly after birth. In severe cases, this can be life-threatening.

• Intracranial bleeding due to rapid compression of the head during delivery.

How to Manage Breech Presentation?

The breech position can be managed at term by,

The External Cephalic Version (ECV) - It is manipulating a fetus to a cephalic presentation through the maternal abdomen. It is performed in the hospital and involves placing hands on the abdomen and applying firm pressure to turn your baby's head down. This technique has a 50 % success rate, but only 10 % of breech presentations spontaneously reverts to normal positions. If this is successful, vaginal delivery can be attempted. The complications of using this technique are:

• Transient fetal heart abnormalities revert to normal. In some cases, this condition can be persistent.

• The placenta may separate from the inner wall of the uterus before birth. This is called placental abruption and results in premature labor.

• The baby might turn back to breech position.

It is contraindicated in individuals with a recent history of bleeding during pregnancy, ruptured membranes, uterine abnormalities, or previous cesarean section.

Cesarean Section- If ECV is unsuccessful, a cesarean section is advised. The risk of morbidity and mortality immediately at birth is high in planned vaginal breech birth cases compared to cesarean in term babies.

Vaginal Breech Birth- Women in advanced labor who have breech presentation may still opt for vaginal delivery. There are three types of vaginal delivery. It includes-

• Spontaneous Breech Delivery- No traction or manipulation of the baby is used in this technique. It happens in very preterm babies.

• Assisted Breech Delivery- This is a prevalent type of vaginal breech delivery. The fetus is allowed to deliver up to the umbilicus spontaneously, and then certain maneuvers are initiated to deliver the remaining part of the body.

• Total Extraction Delivery- The fetal feet are grasped, and the entire fetus is extracted. It should only be used for a noncephalic second twin as the cervix may not be adequately dilated to allow the passage of the head in single pregnancies.

But vaginal breech delivery is contraindicated in the footling breech as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can become trapped.

Conclusion

Vaginal breech delivery requires an experienced obstetrician and careful counseling of the patients. The external cephalic version is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the C-section delivery rate. Parents must be educated about the potential risks and benefits to the mother and neonate for vaginal breech delivery and cesarean delivery. They must also be informed about the risk of Cesarean in subsequent pregnancies and their complications.